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Spirituality and Quality of Life

in Alcoholics Anonymous
a
Alison D. Spalding MSW, PhD & Gary J. Metz MS,
a
MPH, CSAC
a
SUNY Brockport, Alcoholism and Substance Abuse
Studies Program , USA
Published online: 11 Oct 2008.

To cite this article: Alison D. Spalding MSW, PhD & Gary J. Metz MS, MPH, CSAC
(1997) Spirituality and Quality of Life in Alcoholics Anonymous, Alcoholism Treatment
Quarterly, 15:1, 1-14, DOI: 10.1300/J020v15n01_01

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 Spirituality and Quality of Life
in Alcoholics Anonymous
Alison D. Spalding, MSW, PhD
Gary J. Metz, MS, MPH, CSAC
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ABSTRACT. Members of the program of Alcoholics Anonymous

were surveyed with the expectation that certain spiritual perspectives
would be more adaptive than others in the alcoholism recovery pro-
cess in terms of perceived quality of life in sobriety. A collaborative
spiritual coping style was found to be superior to a deferring spiritual
coping style or self-directing spiritual coping style in predicting
better quality of life. Intrinsic versus extrinsic spiritual focus did not
predict quality of life in recovering alcoholics but social support
from friends and family did. [Article copies availablejor ajee fmm The
Haworth Docwnenf Delivery Service: 1-800-342-9678. E-mail address:
gefinfo@hnworth.com]

The purpose of this paper is to report findings on the role of spirituality

as it impacts the quality of life in individuals recovering from alcoholism in
the program of Alcoholics Anonymous (AA). Spirituality as a factor in
alcoholism recovery has been neglected in research (Carroll, 1993; Miller &
McCrady, 1993), yet it is difficult to find an American alcohoVdrug abuse
treatment program which does not embrace a spiritually based 12 step
approach and recommend Alcoholics Anonymous (AA) or other spiritual-
ly based 12 step program attendance (Miller & McCrady, 1993).
When the role of spirituality in recovery hus been explored, operational
definitions have been too broad for interpretation and application (Miller,
1991). If spiritual intervention is reported to be part of a treatment or
recovery program, as is most often the case, it should be operationalized

Alison D. Spalding and Gary J. Metz are affiliated with SUNY Brockport,
Alcoholism and Substance Abuse Studies Program.
Address correspondence to: Alison D. Spalding, SUNY Brockport, 301 New
Campus Drive. Brockport, NY 14420.
Alcoholism Treatment Quarterly, Vol. 1 S(1) 1997
O 1997 by The Haworth Press, Inc. All rights reserved. I
 2 ALCOHOLISM TREATMENT QUARTERLY

where possible, and its impact should be evaluated, along with the impact
of other treatment variables.
Researchers have found that treatment personnel are often oblivious to
the spiritual issues and values of their clients, and of their staff. In the
evaluation of thirteen treatment programs, Lai (1982) found that while
almost all programs said spirituality was important, nine reported no
awareness of the spiritual orientation and practice of their clients and staff.
If this is a trend, it may reflect absence of discussion of spirituality in
alcoholism research.
'Quality of life' also has relevance to the maintenance of successfiA
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sobriety. Those alcoholics who are happy and who embrace a positive self
attitude would seem to be less susceptible to the relapse precipitants which
have been implicated in previous research. One example of such a relapse
precipitant would be 'negative emotional states' (Marlatt & Gordon,
1985). As AA members themselves say, there is a big difference between
sobriety and contented sobriety (Glaser & Ogborne, 1982). If 'spirituality'
impacts quality of life, it may indirectly impact the ability to stay sober,
making life more satisfying and enjoyable in the process.
AA seems to be the ideal place to study the process by which recovery
does or does not occur in a broad population. We need to find out the
process by which change occurs outside of treattnent programs in order to
explore ways for incorporating this recovery component process into treat-
ment programs. Incorporating this component could benefit individuals
who are uncomfortable with the 12 step programs for reasons other than
their spiritual focus, or could potentially assist clients in adjusting to a
spiritual focus prior to, or concurrent with, their exposure to the spiritual
suggestions which are a focus in AA, assisting a smoother transition into
12 step follow-up involvement.
Research suggests that it would be appropriate and beneficial to attempt
to influence spiritual motivation, practice, and coping style if not spiritual
beliefs per se. For example, Carroll (1993) found significant positive
correlations between practice of step 11 of AA: "Sought through prayer
and meditation to improve o w conscious contact with God as we under-
stood Him, praying only for knowledge of His will for us, and the power to
carry that out" (Twelve Steps and Twelve Traditions, 1992, p. 96) and a
measure of perceived purpose in life (along with length of sobriety) in 100
members of AA. Further, Ficter (1982) found that among recovering
clergy members, those who reported that they had a spiritual experience or
awakening during the course of their recovery reported that their therapy
experience had included more experience on spiritual recovery than did
those who had not experienced such an awakening. Those who were
 Alison D. Spalding and Gary J. Metz 3

'awakened' reported greater absolute improvements, and major improve-

ments in the quality of their work and of their interpersonal relationships.
Many therapists do not comprehend why conventional therapeutic un-
derstanding and techniques are not enough to resolve a serious drinking
problem and, after t y n g to apply conventional approaches, will dismiss
the alcoholic as "unmotivated"-not realizing that the task of therapy is to
assist the client in discovering a whole other way of being that is not based
upon willpower alone, or upon other fonns of more conventional motiva-
tion (Berenson, 1987). Clinicians have bcen largely reluctant to incorpo-
rate spirituality into the therapy process, yet purely secular psychotherapy
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may be alien to the two thirds of the US population who consider religion
to be important or very important in their lives (Religion in America,
1985). This majority of the US population may prefer, and may feel more
comfortable with, approaches which are sympathetic to spiritual values
(Bergin, 1991).

SUBJECT POPULATION
The population studied in this project is the 'recovering alcoholic' who
is affiliated with the program of Alcoholics Anonymous. "The only re-
quirement for membership in the fellowship of AA is a desire to stop
drinking" (Alcoholics Anonymous, 1976, p.xiv), and it is therefore as-
sumed that the subjects also met this requirement. A convenience sample
of members of Alcoholics Anonymous was recruited to fill out a series of
standardized instruments, and to answer other written questions in a sur-
vey format. They received no monetary compensation for their participa-
tion. l l e y were recruited by the first author inseveral areas of Alabama,
Georgia, and Virginia. It was required that subjects be at least 18 years of
age in order to participate, and informed consent wasreceived from each
subject. A demographic profile of the subjects is located in the results
section of this paper.
Although confidentiality was assured, anonymity of individual returned
surveys was at the discretion of each subject. Names and addresses were
requested for follow up purposes, but were not required. Subjects were
provided with stamped self addressed envelopes for returning the survey.
The first author approached subjects individually, explaining the purpose
of the study, and requesting participation. Subjects were approached after
Alcoholics Anonymous meetings, and during breaks at Alcoholics Anony-
mous Area Assembly Conventions.
Since no central listing of Alcoholics Anonymous members exists, AA
studies, by necessity, are generally comprised of convenience samples,
and implications of findings must be considered within this context. The
 4 ALCOHOLISM TREATMENT QUARTERLY

authors recognize the limitations of these findings in the area of generaliz-

ability. The results of findings are limited to members of Alcoholics Anon-
ymous groups in specific areas, and are limited to members who were
willing to participate in such a study. Although very few of the AA mem-
bers approached refused to participate outright, approximately 30% of the
subjects who stated that they would complete surveys simply did not
return them by, mail or otherwise.
Despite acknowledged limitations in terms of generalizability, we
maintain that AA provides an obvious source of subjects for longitudinal
studies, and for short term studies. "By definition, those who ever attend
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AA groups will be representative of an alcoholism treatment population"

(Ogborne, 1993, p. 348). To back up this statement, we present findings
from a literature review conducted by Emerick (1989), which compared
all prior studies of alcohol-troubled persons who were in individual treat-
ment for alcoholism. The studies under comparison attempted to deter-
mine variables which distinguished individuals in treatment who partici-
pated in AA from individuals in treatment who did not.
Emerick (1989) determined that the demographic variables of educa-
tion, race, adult social competence, legal status, employment status, paren-
tal SES, type of religion, personal SES, and cognitive functioning were all
unrelated to membership in AA. Other variables which were found to be
inconsistently related to AA membership were age, marital status, gender,
orientation to social contact, social stability and intelligence. These find-
ings, "raise serious doubts about the existence of systematic distinctions
between AA and non-AA members, at least among those alcoholics who
receive conventional alcoholism treatment" (p. 41).

METHODOLOGY
With regard to the independent variable 'spirituality', two standardized
instruments are discussed here. The first instrument assessed spirituality in
the problem solving process (Pargament et al., 1988). This instrument
measured three distinct styles of coping including (a) collaborative (a
problem solving style involving active personal exchange with God);
(b) defening (a problem solving style wherein the individual waits for
solutions from God); and (c) self-directing (a problem solving style which
emphasizes the freedom God gives people to direct their own lives). Ac-
cording to Pargament et al. (1988), those who use both their own, and
spiritual resources (the collaborative style) are generally more psychologi-
cally healthy. In accordance with the above discussion. we hwothesized
that the coilaborative problem solving style would be assdiiated with
bctter quality of life and longer sobriety.
 Alison D. Spalding and Cory J. Melz 5

The second instrument utilized to measure spirituality was an 'Age

Universal' Religious Orientation Scale (Gorsuch and Venable, 1983)
which was developed from Allport and Ross's (1967) widely used
Religious Orientation Scale. This instrument yields two sub-scales: intrin-
sic religious orientation, and extrinsic religious orientation. The 'extrinsic'
individual is said to be religious for some other reason than for the sake of
being religious, such as to develop social relationships or to gain personal
comfort in times of crisis. The 'intrinsic' individual is said to have inter-
nalized beliefs and to live by those beliefs regardless of social pressure and
in good times as well as crisis times. Berenson (1987) equates the extrinsic
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construct with religion, and the intrinsic construct with spirituality.

The person whose scores are elevated on the extrinsic sub-scale is said
to use religion as a means of obtaining security or status. This sub-scale
has been found to correlate positively with pathology, and negatively with
a variety of positive traits including responsibility and internal locus of
control (Bergin et al., 1987). The intrinsic variable is said to reveal an
individual who is religious or spiritual for the sake of being religious or
spiritual, and not to hlfill any other need or value. Scores on the intrinsic
sub-scale have been found to correlate negatively with pathology, and
positively with positive traits such as responsibility and locus of control.
In light of these findings, we hypothesized that individuals who were more
intrinsic would have better quality of life in sobriety than would those who
were more extrinsic.
Gorsuch (1993) suggests that those attempting to measure spirituality
should use one or more of the already existing scales, because new scales
are not needed until more is known about how these established scales
relate to AA. In line with this suggestion, these already established scales
will be the focus for measuring the primary independent variable.
The quality of life (dependent) variable is measured by examining
satisfaction with life, depression levels, self esteem, and sense of symbolic
immortality. The Satisfaction with Life Scale (SWLS) (Diener et al., 1985)
is a five-item scale which measures subjectivc well being and cognitive-
judgmental levels of life satisfaction. The lndex of Self Esteem (ISE) was
designed to measure the degree, severity and magnitude to which a person
has a problem with self esteem (Hudson, 1992). The Sense of Symbolic
Immortality Scale (SSIS) is an instrument designed to measure one's inner
realization of death's inevitability as a way of deriving meaning in life. All
of these instruments have been found to be reasonably reliable and valid,
and further information can be located in original sources.
Other variables measured included severity of alcoholism prior to cur-
rent membership in AA, social support from friends and family, and length
 6 ALCOHOLISM TREATMENT QUARTERLY

of current sobriety. Severity of alcoholism was measured using the MAST,

a very widely known, reliable and valid instrument used frequently in the
alcoholism field. The Provision of Social Relations Scale (PSR) (Turner,
Frankcl, & Levin, 1983) was used to measure perceived social support,
and reveals two sub-scales; one which measures perceived social support
from friends, and one which measures perceived social support fiom family.

RESULTS
The sample population was comprised of 88 members of the program
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of Alcoholics Anonymous (see Table 1). The sample consisted of 50%

male, and 50% female, primarily Caucasian (87.5%) subjects. The mean
age of the subjects was 40.7, and the mean MAST score was 34.4 (a score
higher than 5.0 indicates probable alcoholism). The mean length of time
sober was 64 months. This relatively high mean length of time sober may
reflect the fact that subjects were recruited from both regular AA meet-
ings, and 'area assembly' meetings. Area assembly meetings may attract
individuals who have been involved with AA for longer periods of time,
and who have greater cnthusiasm for AA service work. All findings
should be viewed with this in mind.
The mean age when subjects began drinking was 16.4; and 35.2% of
the subjects never worked out (physically) where approximately 33%
worked out several times a week or every day. About 33% of the subjects
had been married at least once, and were currently manied to one of those
partners. About 26% of subjects had been divorced at least once, and about
18% of subjects had never been married. Thirty-three percent of the sub-
jects had never attended a formal treatment program, and 40 subjects
(43%) had completed at least one treatment program. Sixty four percent of
subjects were steady heavy drinkers, or steady drinkers with heavy binges.
All data analysis was carried out using the Statistical Package for the
Social Sciences (SPSS-x). A correlation table was calculated and ex-
amined using the Pearson's r statistic, and a summary of the findings can
be found in Table 2. Intercorrelations between the independent variables
measuring spirituality were noted, and intercorrelations between the de-
pendent variables were common. Beyond these expected findings, positive
and negative correlations between the sub-scales of the dependent, inde-
pendent, and moderating variables (length of sobriety, social support from
friends, social support from family, and severity of alcoholism) were
noted. These findings pointed to those ordinal and interval level variables
most important for entry into a regression analysis.
For exploration of the nominal variable gender, we examined patterns
among the variables using T-test by groups analysis (see Table 3). Malcs
 Alison D. Spalding and Gary J. Metz 7

and females were compared on each of the sub-scales of the instruments.

As with the correlations tables, the primary purpose in the use of this
procedure was to discern patterns, and relative importance of variables for
inclusion in regression analytic procedures. The cut-off point for signifi-
cance was p < .05. As Table 3 reflects, five variables reached statistical
significance with respect to gender differences. Findings were as follows:
females were found to be more satisfied with life than were males; females
were more likely to use a collaborative spiritual coping style and a defer-
ring spiritual coping style; males were more likely to use a self-directing
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spiritual coping style; and males were more likely to exhibit an intrinsic
spiritual orientation than were females.
A series of multiple regression analyses, stepwise format, were then
carried out in order to explore the role of the independent and moderating
variables in predicting the dependent variables. Other variables which
could account for any positive findings were entered into the various
regression models, and a summary of findings is located in Table 4. In
working with the various models it became apparent that multicollinearity
would be problematic in terms of gender with the sub-scales of the spiritu-
ality instruments, so males and females were separated into two different
groups for detailed analysis.
When the entire subject population was examined, it was apparent that
the Satisfaction with Life Scale was the strongest measure of the depen-
dent variable 'quality of life'. Thus this variable was used in all of the
subsequent equations. Other measures of the dependent variable were
similarly impacted by the same independent variables, but for purposes of
parsimony, only findings related to the Satisfaction with Life Scale will be
reported herein. The independent variables which created the highest R-
square value in the regression equation using all subjects were collabora-
tive spiritual coping style, length of time sober, and social support from
friends (R-square = .46, n = 79).
When a Satisfaction with Life was regressed on the independent vari-
ables in a stepwise format isolating male subjects (n = 42), the best model
utilized three independent variables. The sub-scale 'friends' was entered
first (R-Square = .3 1, beta = - .56, t = .00). [For this and all equations that
follow, it should be noted that higher friends (or family) sub-scale scores
reflect more problems in perceived social support in the area reflected by
the sub-scale.] The second variable entered was length of sobriety in
months, and with this variable, the R-square value was increased to .40,
and the beta was .29 (t = - .02). The third variable in the equation was
collaborative spiritual coping style, which hrther increased the R-square
value to .50, with a beta of .35 (t = .01). When a similar model was created,
 Downloaded by [Stony Brook University] at 20:05 25 October 2014

o TABLE 1. Descriptive Nominal Variables of Study Participants

Variable Categories Number of Subjects Percentage

Gender Female
Male

Race White
Other

Income < 20.000.00 year

21-40,000.00 year
41-70,000.00 year
> 70,000.00 year
Missing data

Educational level HS degree or less

College or BS deg.
Advancedlgrad deg .
Missing data

Occupational Professional/business 36 41 .O%

Status Student 17 19.3%
Assorted other 29 32.9%
Missing data 06 06.8%

Church attendance Rarely or never

Rates Once a month
2-3 times a month
Once a wk. or more
Missing
 Downloaded by [Stony Brook University] at 20:05 25 October 2014

AA attendence rates One rnlg. per mo.

2-3mtgs. per mo.
One or more per wk.
Missing
Sewice w o k Not or minimal
Moderately involved
Heavily involved
Missing
Inpatient treatment Never attended
history Never completed
One prog. completed
Two or more comp.
Missing
Drinking pattern Day B nightheavy
(prior to AA Night onlylheavy
involvement) Consistent whinges
Binges only
Otherhlissing
Workout Never
About 1 time a month
At least one time wk
Marital status Married first time
Married x 2 or more
Divorced x 1 or more
Live together
Single, never married
Widowhvidower
OtherlMissing
 ALCOHOLISM TREATMENT QUARTERLY

TABLE 2. Correlations Among Variables

lntercorrelations Among Measures of the Dependent Variable

(Ouallty of Life)
Satisfaction with Life & Symbolic lmmortaliiy .63"
Satisfaction with Life 8 ~epression
Satisfaction with Life & Anxiety
Satisfactionwith Life & Self Esteem
Depression & Symbolic Immortality
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Depression & Anxiety

Depression & Self Esteem
Anxiety 81Sell Esteem
Anxiety & Symbolic Immortality
lntercorrelations Among
- Measures of the Independent Variable
(Spirituality)
~ollab%ive Coping & Intrinsic Orientation .50"
Deferring Coping 8 Intrinsic Orientation .48"
Collaborative Coping 8 Self-Directing Coping - .32'
Deferring Coping & CollaborativeCoping 63"
Deferring Coping & Self-coping - .41"
lntercorrelations Among Measures of the Dependent Variable
(Quality of Lle) with Measures of the Independent Variables
(Spirituality and Social Support)
Collaborative Coping & Satisfaction with Life .41"
Collaborative Coping & Symbolic Immortality .35'
Collaborative Coping & Anxiety - .35'
Collaborative Coping 8 Self Esteem - .35'
Social Support 8 Satisfaction with Life - .46"
Social Support & Symbolic Immortality - .45"
Social Support & Anxiety .32'

'p< .01; " p c ,001. H~gher~aresonlheselleslwm scaleretleclbwerselfesteam,and higherscoreson

the anx~elyand dspresslon scales rellecl more anxiety and depression. Olherw~fe.higher swres on
scales rellecl hlgher levels of the variable measured

substituting 'family' for 'friends', collaborative spiritual coping style and

length o f sobriety remained significant, while 'family' was deleted from
the equation. Neither o f the other spiritual coping styles were significant
with regard to quality o f life, and neither intrinsic nor extrinsic spiritual
orientation had an impact on quality o f life for males.
When female subjects were similarly isolated (n = 37), length o f sobri-
 Alison D. Spalding and Gary J. Mefz II

TABLE 3. Comparison of Recovering Alcoholics by Gender-2-tail T-Test

Variable Status Number Mean S.D. Prob. of t.

Female '

Age Male
Female
MAST Male
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Satisfaction Female
with Life Male
Symbolic Female
Immortality Male
Depression Female
Scale Male
Anxiety Female
Scale Male
Intrinsic Female
Spirituality Male
Extrinsic Female
Spirituality Male
Collaborative Female
Coping Male
Self-Directing Female
Coping Male
Deferring Female
Coping Male
Social Sup. Female
Friends Male
Social Sup. Female
Family Male

Sobriety in Female
Months Male
Self Female
Esteem Male
 I2 ALCOHOLISM TREATMENT QUARTERLY

TABLE 4. Multiple Regression Models

Models R square Slg. F IV's Beta Slg. T

Coll. cope and length of
sobriety regressed on satisfaction Coll. Cope 0.23 .OO
with life-all subjects N = 79' .46 .OO Length Sob. 0.27 .04
SS Friends -0.46 .OO
Coll. cope, social support from
friends, and length of sobriety Length Sob. 0.34 .OO
regressed on satisfaction with life- SS Friends -0.38 .O1
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male subjects only N = 42 50 .OO Cofl.Cope 0.35 .01

Social support from family and
length of sobriety regressed on
satisfactionwith lif&emale Length Sob. 0.42 .O1
subjects only N = 37 .27 .OO SS Family -0.31 .OO

Social suooort scores are reoresented as where hiaher scores reflect stronaer oerceived ~roblemsin
the $ec~ll~ area measured @~bbrevlahonsCol cLpe = cdlaborat~vecop& ss ~ n e n d ;stands lor
smal sumwrtfromInends.SSFam~lvstandsforsoclalsuDDonfromlamllv.
01 lime Gber in months.
.. - Sob standsfor lenath
. Lemth

ety was the first variable to be entered into the equation, resulting in an
R-square of .18, with a beta of .42 (t = .01). The second variable to be
entered was the 'family' sub-scale, which brought the R-square value to
.27 (beta = .3 1, t = .00).Collaborative spiritual coping style did not remain
significant for females, and none of the other independent variables en-
tered into the regression equation for females.

DISCUSSION AND IMPLICATIONS

The hypothesis that a collaborative spiritual coping style would predict
better quality of life was supported in male subjects. Females subjects, on
the other hand, had higher quality of life and higher collaborative coping
scores than did males in general. Further, length of sobriety predicted
quality of life in all subjects, with longer sobriety associated with better
quality of life. However, we see a discrepancy between male and female
subjects with regard to social support. Whereas females with lower per-
ceived social support from family reported poorer quality of life as mea-
sured on the Satisfaction with Life scale, lower perceived social support
from friends predicted poorer quality of life for males. Hence it appears
that with this population of recovering alcoholics, females are more de-
pendent on satisfactory family relationships for better perceived quality of
life, and males more dependent on satisfactory friendships.
 Alison D.Spalding and Gary J. Metz 13

The findings of this study yield beginning information which may

encourage therapists and treatment staff to take a more active approach to
utilizing spirituality in treatment. Additionally, we should not overlook the
value of the educational component in treatment. It is considered useful
for therapists to be able to demonstrate to the client the connection be-
tween spiritual values and positive mental health consequences. A cogni-
tive awareness of the value of transformation may precede the actual
event, as may be the case within the program of AA as well. A cognitive
awareness of the benefits of incorporating God or a Higher Power into
one's coping repartee may be an entry point for individuals who do not
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elect to involve themselves in AA for any of a variety of reasons.

The findings in the area of social support are also interesting, and
intervention dynamics which incorporate social skills training, assertive-
ness training, acceptance of others, and decision making regarding which
relationships are worthy of continued investment (emotional and other-
wise) are some of the areas that could be addressed in counseling. Females
may need a heavier focus on improving social relationships with family
members, whereas males may need a heavier focus on improving social
relationships with friends. However, a review of the correlations findings
(Table 2) shows us that positive social relationships with friends are
associated with better quality of life (and negative relationships with
friends associated with poorer quality of life) for all recovering alcoholics
in this study.

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